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Telepsychiatry-based Cultural Sensitivity Collaborative Treatment is a promising and effective model to improve treatment of depression in underserved racial and ethnic minority populations. Details here.
Depression is the leading cause of disability and a major contributor to the global burden of disease as measured in disability-adjusted life years, according to a report in 2017 by the World Health Organization.1 By 2030, depression is projected to become the world’s largest contributor to disability-adjusted life years.2 Patients with depression are more likely to have chronic comorbid medical conditions such as diabetes and congestive heart failure and are more likely to be nonadherent to prescribed medications. Patients with untreated depression have higher medical costs, worse health outcomes, and lower quality of life than those whose depression is treated.
Disparities in treatment
There are tremendous disparities in the treatment of depression. Racial and ethnic minorities face both practical and cultural barriers to mental health care. They frequently lack the resources to seek help, suffer from language barriers, and hold strong convictions of stigma about psychiatric illnesses. These obstacles lead to under-recognition and undertreatment of mental illnesses. The Surgeon General’s Report considered correcting these disparities a top priority and suggested offering minority-centered services and developing culturally competent care to address the specific needs of minorities.3
Research has shown that the mental health care system provides less care to African Americans, who also are less likely to seek mental health care than white Americans. When African Americans seek mental health care, they are less likely to be satisfied with the care they receive-and more likely to leave treatment prematurely.4 This can be explained by a history of mistrust of medical professionals that originated from unethical treatment of racial and ethnic minorities in research and practice, which led a greater proportion of minorities to be skeptical of mental health care. These help-seeking behaviors may explain why African Americans with major depression are more likely to experience higher degrees of functional limitation.5
Asian Americans have their distinctive patterns of illness beliefs. When depressed, Asian Americans tend to focus on physical symptoms and under-report mood and anxiety symptoms. They usually prefer to seek help from primary care physicians (PCPs), lay people, and alternative medical practices, and rarely utilize mental health services.6 This help-seeking behavior makes primary care an important setting for identifying and treating depressed Asian Americans, yet depression is frequently under-recognized and undertreated in primary care.
The tendency of depressed Asian Americans to focus on their physical symptoms renders depression particularly difficult to identify in this population. When PCPs recognize depressed Asian Americans, they frequently feel that they lack the cultural understanding to effectively and sensitively communicate to patients about their illness. PCPs worry that informing their patients about MDD may provoke stigma against having mental illness. Under-treatment of depression among Asian Americans remains a significant public health problem in the US.
Collaborative management in primary care
The Chronic Care Model has been shown to improve outcomes in many chronic diseases, including diabetes, congestive heart failure, asthma, hyperlipidemia, and depression. Proposed by Wagner and colleagues,7 it includes the following strategies:
1. Population-based care
2. Use of treatment protocols with proven effectiveness for clinical management
3. Patient-centered collaborative goal setting
5. Planned and regular follow-up visits
6. Care management
Based on the Chronic Care Model, Katon and colleagues8 designed a collaborative model of treatment of depression in primary care: the PCP and a psychiatrist provide interventions, intensive patient education, and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. This collaborative management resulted in more favorable outcomes for depression and improved satisfaction among patients with MDD.
There are significant cultural barriers to implementing collaborative management of depression for Asian American immigrants. Many of these individuals are unfamiliar with the concept of major depression, have language barriers, and schedule physician visits only if they have physical symptoms. Physicians with inadequate cultural sensitivity may overlook depression among this population. When depression is diagnosed, many Chinese Americans avoid mental health services because of their culture’s strong stigma against psychiatric disorders. To overcome these cultural barriers, the Engagement Interview Protocol (EIP), a culturally sensitive assessment, can be used to explore patients’ illness beliefs, their understanding of the illness, and what they hope to achieve from treatment.9 This information is particularly useful for engaging minority populations.
Telemedicine, in the form of videoconferencing, brings tremendous opportunities to clinical care, education, research, and administration. Psychiatry is an ideal specialty for the application of telemedicine. Diagnostic and treatment information in psychiatry can be transmitted through audiovisual communication where there is a desperate need to extend mental health services to underserved populations in rural and inner-city areas. Telepsychiatry-together with telecardiology, teledermatology, and teleradiology-is considered an important telemedicine specialty. With the increasing availability of broadband systems, whether satellite-based, cable, fiber, or digital subscriber lines, there are more opportunities to provide telepsychiatry services to any place in the world.
In the development of telepsychiatry, areas of investigation have included its reliability, patient satisfaction, effectiveness of communication, and its effect on the clinician-patient relationship. Reliability studies that compared telepsychiatric services with in-person care have shown high interrater reliability across a wide range of psychiatric disorders including anxiety, cognitive decline, depression, and psychosis.10 In general, interrater reliability and diagnostic reliability appear to be excellent with telepsychiatry. Moreover, children, adolescents, adults, and geriatric patients have reported high satisfaction with telepsychiatry.
Based on a meta-analysis of studies that compared in-person psychiatric assessment with telepsychiatry assessment, Hyler and colleagues11 concluded that there was no difference in accuracy or satisfaction between the 2 modalities. They predicted that telepsychiatry will replace in-person interviews in certain research and clinical situations. After conducting a comprehensive review of the literature on telepsychiatry applications, Hilty and colleagues12 found that telepsychiatry is feasible and increases access to care, enables specialty consultation, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms of communication, generally satisfies patients and providers, and is empowering to those who use it.
Culturally sensitive collaborative treatment using telepsychiatry
Telepsychiatry-based Cultural Sensitivity Collaborative Treatment (T-CSCT) uses advanced telemedicine technology to address the growing number of culturally diverse immigrants in areas with little or no bilingual and bicultural mental health services. Adding a culturally sensitive assessment conducted via videoconferencing to Katon’s collaborative care model provides an innovative depression management program to promote culturally sensitive care.
From 2008 to 2013, my team at the South Cove Community Health Center in Boston studied the feasibility and effectiveness of T-CSCT.13Table 1 lists the 4 components that were included in the study. Chinese American patients who participated in the study were asked to complete the Chinese Bilingual Patient Health Questionnaire-9 (CB-PHQ-9)14 during their annual physical examination. They returned the questionnaire before their visits, and their PCPs discussed the results of the screening and recommended follow-up and/or treatment when indicated.
Patients who screened positive for MDD (total CB-PHQ-9 score, ≥ 10) were contacted by phone about the results of their screening and were invited to join the study. Patients who consented to join the study were scheduled to have a culturally sensitive psychiatric assessment at the health center via videoconferencing with a bilingual psychiatrist who was physically located at Massachusetts General Hospital.
The Polycom® VSXTM3000 system was installed at the health center recruitment sites and at Massachusetts General Hospital. This standards-compliant compact videoconference system provides excellent audio and video quality. The systems were connected using internet protocol or Integrated Services Digital Network (ISDN) networking. All videoconferences were encrypted using the Advanced Encryption Standard to provide security during data transmission. The transmissions were at 384 kbps with no audio delay.
In 2011, the Polycom videoconferencing systems were replaced by webcams when web-based videoconferencing became available via Skype. The web-based system was inexpensive to install and required less technical support than landlines and ISDN networking. While Skype is free, it is not HIPAA compliant for telehealth; Skype for Business technically has the sufficient encryption needed for telepsychiatry, but it is not free.
Since many Chinese immigrants had low mental health literacy and strong stigma against receiving mental health services, culturally sensitive assessment was performed using the EIP. This semi-structured instrument is designed to bridge illness beliefs of people from diverse cultural backgrounds with the psychiatric framework described by DSM. The EIP includes exploration of the patient’s narratives and illness beliefs, disclosure of the patient’s psychiatric illness in a way that is compatible with his or her illness beliefs, and negotiation of treatment of depression that is agreeable to the patient. Interviewing with the EIP allows clinicians to discuss patients’ illnesses and treatment options using language and a framework that are relevant to the context of their lives and to avoid psychiatric jargon that is unfamiliar to patients.
In the T-CSCT study, specific EIP-based questions were asked to explore illness beliefs (Table 2). With knowledge of the patient’s illness beliefs, the psychiatrist disclosed the diagnosis of depression in ways that were compatible with those beliefs and discussed treatment options.
After psychiatric assessment, patients with confirmed MDD were encouraged to seek treatment from their PCP, who received a letter about the patient’s diagnosis and a recommended treatment plan. Patients could also choose to seek treatment or consultation from a psychiatrist or a therapist.
Care managers were accessible to patients via telephone and served as a link between patients, PCPs, and consulting psychiatrists. They facilitated patients’ depression treatment and coordinated visits with psychiatrists and psychologists. A psychiatrist provided weekly supervision to care managers, as well as consultations with patients and their PCPs.
At the beginning of the study, a bilingual care manager met with patients to establish rapport, explain the role of the care manager, and provide education on MDD. After the initial meeting, the care manager contacted the patient monthly for 6 months using telephone calls to monitor the patient’s depressive symptoms, adherence to medication treatment, management of adverse events, and knowledge of self-management strategies.
T-CSCT is a promising and effective model to improve treatment of MDD for underserved racial and ethnic minority populations. We encourage future replications and testing of this approach to other racial and minority groups with diverse cultural backgrounds who suffer from disparities in depression treatment.
Dr. Yeung is Associate Professor of Psychiatry, Harvard Medical School, Boston, MA. Dr. Yeung reports no conflicts of interest concerning the subject matter of this article.
1. World Health Organization. Depression Fact Sheet; February 2017. http://www.who.int/mediacentre/factsheets/fs369/en/. Accessed November 2, 2017.
2. World Health Organization. Depression, A Global Crisis; 2012. http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf. Accessed November 2, 2017.
3. US Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General–Executive Summary. https://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf. Accessed November 2, 2017.
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14. Yeung A, Fung F, Yu SC, et al. Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. Compr Psychiatry. 2008;49:211-217.